Health systems utilize a variety of models when looking at the population of patients for which they provide care. One typical model is a stratification of the patient population based on risk and/or cost. Risk, in turn, may be based on, for example, a number of disease conditions associated with a particular patient. This type of model may be useful if a health system is attempting to determine how much it will spend on patient care in the upcoming year. However, these types of models may not be useful for identifying patients that may need some type of clinical intervention, nor are they useful for identifying what type of intervention is needed. As an example, under traditional models, a patient may be suffering from multiple, chronic disease conditions and thus be considered a “high-risk” patient that has a high cost of care. However, this patient may be well-managed and therefore not in need of any type of clinical intervention. Current models fail to make this distinction.